Are 80 Hours Per Week Enough or Too Little for Residents and Fellows?

Abstract

Effective July 2003, the Accreditation Council for Graduate Medical Education (ACGME) established that residents and fellows (hereafter collectively referred to as residents) may not work more than 80 hours per week, averaged over 4 weeks. Moreover, there could not be more than 30 hours of in-hospital call or less than a 10-hour break between shifts. Since then, the ACGME has conferred occasional exemptions for programs to allow residents work 88 hours per week (almost exclusively for surgery residencies). At the same time, citations have been administered by the ACGME to programs that fail to comply with new work hour restrictions, with the number of citations totaling 135 from 2003–2004. Many medical educators argue that training physicians is hampered by the new ACGME rules.1Charap M. Reducing resident work duty hours Unproven assumptions and unforeseen outcomes.Ann Intern Med. 2004; 140: 814-815Crossref PubMed Google Scholar, 2Ryan J. Unintended consequences the accreditation council for graduate medical education work-hours rule in practice.Ann Intern Med. 2005; 143: 82-83Crossref PubMed Scopus (16) Google Scholar Moreover, the actual time that all residents are able to devote to daily and weekly conferences and obtain the benefits of informal discussions that serve as a platform for medical education is impaired. Some recent studies demonstrated that medical errors correlate with work hours by residents. For example, interns working in a medical intensive care unit made significantly more serious medical errors if they worked frequent shifts of 24 hours or more than if they worked shorter shifts and worked fewer hours per week.3Landrigan C.P. Rothschild J.M. Cronin J.W. Kaushal R. Burdick E. Katz J.T. Lilly C.M. Stone P.H. Lockley S.W. Bates D.W. Czeisler C.A. Effect of reducing interns’ work hours on serious medical errors in intensive care units.N Engl J Med. 2004; 351: 1838-1848Crossref PubMed Scopus (1318) Google Scholar Furthermore, the shorter shifts resulted in quantitatively more sleep and qualitatively fewer attentional failures among the interns.4Lockley S.W. Cronin J.W. Evans E.E. Cade B.E. Lee C.J. Landrigan C.P. Rothschild J.M. Katz J.T. Lilly C.M. Stone P.H. Aeschbach D. Czeisler C.A. Harvard Work Hours, Health and Safety GroupEffect of reducing interns’ weekly work hours on sleep and attentional failures.N Engl J Med. 2004; 351: 1829-1837Crossref PubMed Scopus (714) Google Scholar In a mixed-method multi-institutional study, residents across different specialties noted an important impact of sleep loss of the ability to perform a variety of functions well.5Papp KKM Stoller E.P. Sage P. Aikens J.E. Owens J. Avidan A. Phillips B. Rosen R. Strohl K.P. The effects of sleep loss and fatigue on resident-physicians a multi-institutional, mixed–method study.Acad Med. 2004; 79: 394-406Crossref PubMed Scopus (201) Google Scholar However, a systematic review of 7 studies examining the effects of work hours on patient safety failed to demonstrate any clear relationship between work duty hours and patient safety.6Rosenbaum J.R. Can residents be professional in 80 or fewer hours a week?.Am J Med. 2004; 117: 846-850Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar Further studies are needed to examine the impact of these restrictions on patient safety, continuity of care, and medical education for our trainees.7Fletcher K.E. Davis S.Q. Underwood W. Mangrulkar R.S. McMahon Jr, L.F. Saint S. Systematic review effects of resident work duty hours on patient safety.Ann Intern Med. 2004; 141: 851-857Crossref PubMed Scopus (173) Google Scholar Dr. Mark Babyatsky, Vice-Chair of Education, Program Director of the Internal Medicine Residency at the Mount Sinai Medical Center in New York, and a physician-scientist examining neuro-immune interactions in inflammatory bowel disease, believes that the advantages and disadvantages of the new rules still require ongoing evaluation, and that consensus will emerge over time. The reader is referred to the growing and widely cited literature in this topic.